How is starvation ketosis treated?

Treatment of Starvation Ketosis

The primary treatment for starvation ketosis is oral ingestion of 150-200g of carbohydrate daily (45-50g every 3-4 hours) to reduce or prevent ketosis, along with adequate fluid intake to prevent dehydration. 1, 2, 3

Initial Management

• Begin with isotonic saline (0.9% NaCl) at 15-20 ml/kg/hour during the first hour to restore circulatory volume and tissue perfusion 2, 3
• After initial fluid resuscitation, transition to dextrose-containing fluids (D5 1/2NS) to provide glucose and halt ketogenesis 2, 4
• If the patient is unable to tolerate oral intake, intravenous dextrose should be administered until oral feeding can be resumed 2, 3
• Monitor blood glucose levels every 1-2 hours initially to prevent both hypoglycemia and hyperglycemia 4

Carbohydrate Replacement

• Provide 150-200g of carbohydrate per day (45-50g every 3-4 hours) to effectively reduce or prevent starvation ketosis 1, 2
• If regular food is not tolerated, liquid or soft carbohydrate-containing foods such as sugar-sweetened soft drinks, juices, soups, and ice cream should be consumed 1
• Pure glucose is the preferred treatment, but any form of carbohydrate that contains glucose will raise blood glucose 1
• Consuming 15g of carbohydrates will raise blood glucose by approximately 40 mg/dl over 30 minutes 3

Electrolyte Management

• Monitor serum electrolytes, particularly potassium, sodium, and phosphate levels closely 2, 3
• Once renal function is assured, add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) to the infusion until the patient can tolerate oral supplementation 2, 3
• Increase fluid intake to prevent dehydration; replacement fluids containing sodium, such as broth, tomato juice, and sports drinks are helpful 1

Monitoring for Resolution

• Treatment success is indicated by resolution of acidosis (pH >7.3), serum bicarbonate ≥18 mEq/L, anion gap ≤12 mEq/L, and improvement in clinical symptoms 2
• During therapy, monitor blood every 2-4 hours for determination of serum electrolytes, glucose, blood urea nitrogen, creatinine, and osmolality 2, 3
• Check ketone levels to track resolution of ketosis 4

Special Considerations

• In patients with concurrent nausea and vomiting, antiemetic treatment is essential to break the cycle and allow for oral intake 4
• For patients at risk of refeeding syndrome (severely malnourished individuals), start nutritional support at a lower rate and monitor electrolytes closely 5
• SGLT2 inhibitors should be stopped at commencement of very low-energy diets to prevent ketoacidosis in patients at risk 2

Differentiating from Other Ketotic States

• Starvation ketosis is distinguished from diabetic ketoacidosis (DKA) by clinical history and plasma glucose concentrations that range from mildly elevated to hypoglycemic 1, 3
• Unlike DKA, serum bicarbonate in starvation ketosis is usually not lower than 18 mEq/L 1, 3
• Alcoholic ketoacidosis (AKA) can be differentiated by history of alcohol intake and can result in profound acidosis 1

Common Pitfalls to Avoid

• Inadequate carbohydrate replacement (less than 150-200g daily) may lead to persistent ketosis 2
• Failure to monitor electrolytes and acid-base status may lead to complications 2
• Failing to distinguish between starvation ketosis and diabetic ketoacidosis may lead to inappropriate insulin administration 4
• Refeeding syndrome can occur when nutrition is reintroduced too rapidly in severely malnourished patients 5, 6